[Usefulness of transesophageal echocardiography during myocardial revascularization surgery without extracorporeal circulation]. / Utilidad de la ecocardiografía transesofágica intraoperatoria durante revascularización miocárdica sin circulación extracorpórea.

OBJECTIVE: Intraoperative transesophageal echocardiography can be a highly useful monitoring technique during myocardial revascularization surgery when extracorporeal circulation (ECC) is not being used. Transesophageal echocardiography provides real-time images on both volume status and segmental myocardial contractility without interfering with the surgical field. PATIENTS AND METHODS: A total of 25 patients undergoing myocardial revascularization by sternotomy without ECC were monitored by transesophageal echocardiography during surgery. RESULTS: The 18 men and 7 women studied had a mean (SD) age of 71.3 (8) years. A third of them had hypertension and diabetes, 3 had suffered a cerebrovascular accident, and 2 had renal failure. Nine patients had a history of acute myocardial infarction and 3 had undergone angioplasty. Baseline echocardiograms on all patients established that 6 had a low ejection fraction (<30%). Twelve had altered segmental contractility, which was transient in 11 cases. Six patients had improved ejection fraction at the final assessment. Transesophageal electrocardiography also monitored volume status and the effects of inotropic drugs and beta-blockers in 83% of the patients. CONCLUSION: Transesophageal electrocardiography is a minimally invasive, safe, and precise way to directly monitor the beating heart in real time during myocardial revascularization without ECC. Image quality is good.

[Intracoronary air embolism detected during intraoperative transesophageal echocardiography]. / Detección de embolia aérea intracoronaria con ecocardiografía transesofágica intraoperatoria.

A 39-year-old hypertensive man with severe aortic stenosis underwent aortic valve replacement monitored by intraoperative transesophageal echocardiography. Upon weaning the patient off extracorporeal circulation, hemodynamics became severely compromised, with hypotension, tachycardia, and elevated precordial electrocardiographic tracings. The echocardiographic images were instrumental during the episode to demonstrate that the anterior wall presented hypokinesis consistent with ischemia in the region but that there were also images of hyperrefringence highly suggestive of intracoronary air embolism. Intraoperative transesophageal echocardiography allowed us to diagnose the real cause of the ischemic event and rule out an atheromatous plaque as the source. Perfusion pressure was increased to treat the air embolism. The echocardiographic image demonstrated success, specifically restoration of left ventricular regional contractility. This experience revealed the usefulness of transesophageal echocardiography in intraoperative monitoring to diagnose ischemia, assess the cause, and guide treatment.

[Intraoperative measurement of cardiac output by transesophageal echocardiography of transmitral flow]. / Medición de gasto cardíaco a nivel de válvula mitral con ecocardiografía transesofágica intraoperatoria.

INTRODUCTION: Intraoperative transesophageal echocardiography is used to study cardiac structure and function. Cardiac output is measured by calculating the velocity with which a volume of blood travels a predetermined area. Output can be assessed at the mitral valve by parallel alignment of the Doppler transducer to measure flow velocity. OBJECTIVE: To compare cardiac output measurements from transesophageal echocardiography with measurements performed by the standard clinical technique of thermodilution. PATIENTS AND METHODS: Cardiac output measurements obtained by thermodilution and by echocardiography at the mitral valve were compared in a prospective study during 34 cardiac surgery procedures. RESULTS: Cardiac output measurements ranged from 2.3 L min(-1) to 7.8 L min(-1) (mean 4.27 +/- 0.125 L min(-1) for measurements made by Doppler echocardiography and from 1.9 L min(-1) to 8.1 L min(-1) (mean 4.36 +/- 0.124 L min(-1)) for measurements made by thermodilution. The correlation between the methods was high (r = 0.926, p = 0.00001). CONCLUSION: Intraoperative measurement of cardiac output by transesophageal Doppler echocardiography at the mitral valve is easy and correlates highly with the clinical method of thermodilution used at present. Use of the technique will widen the spectrum of information provided by echocardiography, which is a safe, minimally invasive technique.

Utilidad de la ecocardiografía transesofágica intraoperatoria durante revascularización miocárdica sin circulación extracorpórea / Usefulness of transesophageal echocardiography during myocardial revascularization surgery without extracorporeal circulation

OBJETIVO: La ecocardiografía transesofágica intraoperatoria(ETE) puede ser un sistema de monitorización dealta utilidad durante la revascularización miocárdica sincirculación extracorpórea (CEC), ya que permite obtenerimágenes en tiempo real tanto del estado de la volemiacomo de la contractilidad segmentaria miocárdica, sininterferir en el campo quirúrgico.PACIENTES YMÉTODOS: Se estudian 25 pacientes sometidosa revascularización miocárdica por esternotomía sinCEC monitorizados con ETE durante su intraoperatorio.RESULTADOS: 18 hombres y 7 mujeres, con edad promediode 71,3 ± 8 años fueron estudiados. Un tercio de ellospresentaba hipertensión arterial y diabetes, 3 habían tenidoun accidente vascular encefálico previo y 2 eran portadoresde insuficiencia renal. Un total de 9 pacientes teníahistoria de infarto agudo al miocardio y 3 casos de elloshabían sido sometidos a angioplastias previas. A todos lospacientes se les realizó ETE basal donde seis tenían malafracción de eyección (FE) < 30%. Se detectaron alteracionesde la contractilidad segmentaria en 12 pacientes, deéstos en 11 fueron alteraciones sólo transitorias. En la evaluaciónfinal se determinó que en 6 enfermos hubo unamejoría de la FE. La ETE permitió además evaluar elestado de la volemia, el efecto de fármacos inotropos y betabloqueadores en el 83% de los pacientes.CONCLUSIÓN: La ETE es un monitor mínimamenteinvasivo y en tiempo real que permite evaluar en formadirecta, segura y precisa al corazón latiendo durante larevascularización miocárdica sin CEC con buena calidadde imágenes

OBJECTIVE: Intraoperative transesophageal echocardiographycan be a highly useful monitoring techniqueduring myocardial revascularization surgery whenextracorporeal circulation (ECC) is not being used.Transesophageal echocardiography provides real-timeimages on both volume status and segmental myocardialcontractility without interfering with the surgicalfield.PATIENTS AND METHODS: A total of 25 patients undergoingmyocardial revascularization by sternotomy withoutECC were monitored by transesophageal echocardiographyduring surgery.RESULTS: The 18 men and 7 women studied had amean (SD) age of 71.3 (8) years. A third of them hadhypertension and diabetes, 3 had suffered a cerebrovascularaccident, and 2 had renal failure. Nine patientshad a history of acute myocardial infarction and 3 hadundergone angioplasty. Baseline echocardiograms on allpatients established that 6 had a low ejection fraction(<30%). Twelve had altered segmental contractility,which was transient in 11 cases. Six patients had improvedejection fraction at the final assessment. Transesophagealelectrocardiography also monitored volumestatus and the effects of inotropic drugs and ß-blockersin 83% of the patients.CONCLUSION: Transesophageal electrocardiography isa minimally invasive, safe, and precise way to directlymonitor the beating heart in real time during myocardialrevascularization without ECC. Image quality isgood

Detección de embolia aérea intracoronaria con ecocardiografía transesofágica intraoperatoria / Intracoronary air embolism detected during intraoperative transesophageal echocardiography

Se presenta el caso clínico de un paciente de 39 años, portador de hipertensión arterial y estenosis aórtica severa sometido a recambio valvular aórtico, que fue monitorizado con ecocardiografía transesofágica intraoperatoria (ETE). Al finalizar la circulación extracorpórea presentó compromiso severo de su estado hemodinámico, caracterizado por hipotensión, taquicardia y elevaciones del trazado electrocardiográfico en la pared anterior miocárdica. Durante este episodio las imágenes ecocardiográficas fueron útiles y categóricas para demostrar que la pared anterior presentaba hipocinesia compatible con isquemia de este territorio, pero además existieron en esta zona imágenes de hiperrefringencia altamente sugerentes de aire intracoronario. La ETE permitió diagnosticar la causa de este fenómeno isquémico, desestimando como etiología una placa ateromatosa. El tratamiento de la embolía aérea intracoronaria fue aumentando la presión de perfusión, cuyo éxito se evidenció también con la ecocardiografía que demostró la restauración de contractilidad segmentaria del ventrículo izquierdo. A través de la evolución de este paciente se evidenció la alta utilidad de la ecocardiografía transesofágica como monitor intraoperatorio para diagnosticar isquemia, estimar su etiología y guiar su terapia

A 39-year-old hypertensive man with severe aortic stenosis underwent aortic valve replacement monitored by intraoperative transesophageal echocardiography. Upon weaning the patient off extracorporeal circulation, hemodynamics became severely compromised, with hypotension, tachycardia, and elevated precordial electrocardiographic tracings. The echocardiographic images were instrumental during the episode to demonstrate that the anterior wall presented hypokinesis consistent with ischemia in the region but that there were also images of hyperrefringence highly suggestive of intracoronary air embolism. Intraoperative transesophageal echocardiography allowed us to diagnose the real cause of the ischemic event and rule out an atheromatous plaque as the source. Perfusion pressure was increased to treat the air embolism. The echocardiographic image demonstrated success, specifically restoration of left ventricular regional contractility. This experience revealed the usefulness of transesophageal echocardiography in intraoperative monitoring to diagnose ischemia, assess the cause, and guide treatment

Medición de gasto cardíaco a nivel de válvula mitral con ecocardiografía transesofágica intraoperatoria / Intraoperative measurement of cardiac output by transesophageal echocardiography of transmitral flow

INTRODUCCIÓN: La ecocardiografía transesofágica intraoperatoria se utiliza para el estudio anatómico y funcional del corazón. El gasto cardíaco se mide calculando la velocidad con que un volumen de sangre atraviesa un área predeterminada. A nivel de la válvula mitral se puede determinar el gasto cardíaco y además permite la alineación paralela del transductor doppler para la medición de las velocidades. OBJETIVO: Comparar las mediciones realizadas de gasto cardíaco con ecocardiografía transesofágica a nivel de la válvula mitral con las mediciones realizadas con la técnica estándar utilizada en la clínica actualmente que es la técnica de termodilución. PACIENTES Y MÉTODOS: En forma prospectiva se compararon las mediciones de gasto cardíaco realizadas con termodilución con las mediciones realizadas con ecocardiografía a nivel de la válvula mitral durante el intraoperatorio de 34 cirugías cardíacas. RESULTADOS: Los rangos de los valores de gasto cardíaco fueron entre 2,3 l min-1 y 7,8 l min-1 (media de 4,27 ñ 0,125 litros min-1) para las mediciones con doppler y de 1,9 l min-1 y 8,1 l min-1 (media de 4,36 ñ 0,124 l min-1) para las mediciones realizadas con termodilución. La correlación entre ambas técnicas fue alta (r = 0,926 p = 0,00001). CONCLUSIONES: La medición del gasto cardíaco con ecocardiografía transesofágica intraoperatoria a nivel de la válvula mitral es fácil y se correlaciona bien con el método clínico de termodilución empleado en la actualidad, lo que amplía el espectro de información aportado por la ecocardiografía, que es una técnica mínimamente invasiva y segura (AU)